COLLEGE OF FAMILY PHYSICIANS SINGAPORE
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1 COLLEGE OF FAMILY PHYSICIANS SINGAPORE MMED (FAMILY MEDICINE) - COLLEGE PROGRAMME Intake Recent Passport-sized Photograph x 1 APPLICATION FORM Please the appropriate boxes accordingly. * Delete where applicable (A) PERSONAL PARTICULARS Family Name : Given Name : Nationality : Singaporean / Singapore PR / Others * (please specify): Sex : Male / Female * Passport / NRIC No : Date of Birth : (dd / mm / yyyy) Race : Chinese / Malay / Indian / Others* (please specify) : Residential Address : Postal Code : Singapore Telephone (Home) : Mobile Phone^ : Address^ : (B) PRACTICE INFORMATION MCR No: Year of SMC Registation: Year of Graduation: Medical Registation Type: *Full / Conditional Type of Practice : NHG NUHS SingHealth Community Hospital Locum Private-Group Private-Solo Others: Practice Address : Postal Code : Singapore Telephone (Office) : Fax (Office) : Please indicate your preferred mailing address with a tick : Residential Practice Address (C) COLLEGE MEMBERSHIP INFORMATION Are you a College member : Yes No Pending ^Mobile phone number and address will be reflected in the MMed Logbook. Please ensure that this is the account you would check regularly; course information will be sent to the as provided.
2 (D) OTHER INFORMATION Degrees / Diplomas Awarded (Attach a separate sheet if necessary) Qualification Year Appointments (Attach a separate sheet if necessary) Position Held Department Hospital / Medical Group / Practice From (Month / Year) To (Month / Year) Remarks (if any) I am applying for the MMed (Family Medicine) - College Programme Subsidy: Yes / No If No, please complete section (E) below. If Yes, please complete sections (E), (F) and (G) below. (E) DECLARATION 1. I hereby make an application for the MMed (Family Medicine) - College Programme and declare that all the information I have supplied on this application form is, to the best of my knowledge, complete and correct. 2. I also declare that I am not concurrently enrolled in another postgraduate/degree/diploma programme; and if found to be otherwise, any offer of enrolment will be withdrawn. 3. I acknowledge that my application for enrolment is subjected to the admission criteria and examination eligibility as advised by DGMS. 4. I further acknowledge that by signing this, I have read and agreed to abide by the Terms & Conditions as stated under Important Notes. Please send the completed application form (with photograph attached) together with a cheque payment (S$14,412.90* for College members; S$15,985.80* for non-college members) made payable to before 11 May 2018 to: * Inclusive of 7% GST
3 (F) DECLARATION for the MMed(FM) - College Programme Subsidy 1. I hereby make an application for the MMed (Family Medicine) - College Programme Subsidy and declare that all the information I have supplied on this application form is, to the best of my knowledge, complete and correct. 2. I acknowledge that my application for enrolment is subjected to the admission eligibility criteria for the MMed (Family Medicine) - College Programme, examination and the MMed (Family Medicine) - College Programme Subsidy as advised by CFPS, DGMS and MOH respectively. 3. I acknowledge that by signing this, I have read and agreed to abide by the Terms & Conditions as stated under Important Notes. 4. I declare that I do not have any disciplinary record with the SMC. Please send the completed application form (with photograph attached) together with a cheque payment (S$ * for College members; S$7,992.90* for non-college members) made payable to by 11 May 2018 to : * Inclusive of 7% GST (G) LETTER OF UNDERTAKING for the MMed(FM) - College Programme Subsidy I hereby confirm my acceptance of the Terms and Conditions as spelt out by the Ministry of Health regarding the MMed (Family Medicine) - College Programme Subsidy as stated in the Important Notes section of this Application Form. I affirm that all statements made by me in the application form are correct. I understand that in the event that I am unable to satisfy any one of the eligibility criteria of this MMed (Family Medicine) - College Programme Subsidy, I will refund the entire subsidy in accordance with the terms and conditions. I acknowledge that the decisions of the Administrator of MMed (Family Medicine) - College Programme Subsidy shall be final and any appeals must be made in writing to the Administrator who will then forward it to the Ministry of Health for further consideration. FOR OFFICIAL USE ONLY Fee Paid : S$ Acknowledgement date : Cheque / Draft No : Official Receipt No : Checked by :
4 Important Notes Course Fee Course fee does not include fees for advanced FM course, BCLS and examination. (Examination fees to be made payable to National University of Singapore upon registration for the examination.) Refund Policy a) CFPS will charge applicant a non-refundable registration fee of S$1,605 (inclusive of 7% GST) if the request for withdrawal from the course is made in writing by 4 June b) Strictly no refund of fees on or after 5 June MMed (Family Medicine) - College Programme MOH Subsidy 1) The 50% Subsidy covers: MMed (Family Medicine) - College Programme Course Fees One round of MMed (Family Medicine) Preparatory Course 2) Eligibility Criteria: Doctors will need to fulfil the following requirements to be eligible for subsidy: Fulfilled entry requirements for the MMed (Family Medicine) - College Programme as set out by CFPS Singapore Citizen or Permanent Resident Good disciplinary record with SMC Satisfactory completion of the MMed (Family Medicine) - College Programme Attempt the MMed (Family Medicine) - College Programme exam (second attempt is required if first attempt is unsuccessful) 3) Refund Policy: All applicants have to sign the Letter of Undertaking (see section G of this application form). Trainees who fail to fulfil the requirements under the eligibility criteria are expected to refund any subsidies provided. To clawback the funds provided, MOHH will deduct the requisite amount from the salary of the trainee and transfer the amount to MOH. Trainees who do not receive a salary from MOHH must make a direct payment to MOH. 4) Doctors who are sponsored by their institutions / employers are not eligible for the MOH Subsidy. 5) Number of applications: Up to 21 applicants can be subsidised for MMed(FM) College Programme
5 All feedback/correspondence related to the MMed (Family Medicine) - College Programme should be addressed to: MMed(FM) Programme Director Tel: Fax: mmed@cfps.org.sg Website: The 2018 MMed(FM) course is tentatively scheduled to commence on 4 July All feedback / correspondence related to the MOH subsidy for MMed (Family Medicine) - College Programme should be addressed to: JCFMS Secretariat Division of Graduate Medical Studies Yong Yoo Lin School of Medicine, National University of Singapore, Blk MD3, Level 2, 16 Medical Drive, Singapore Tel: / gsmssh@nus.edu.sg / gsmtymj@nus.edu.sg
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